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Journal of Intensive Care Medicine, Vol. 18, No. 4, 175-188 (2003)
DOI: 10.1177/0885066603254249
© 2003 SAGE Publications

Reviews

Nosocomial Pneumonia in the Intensive Care Unit: Controversies and Dilemmas

Ravindra M. Mehta, MD

Division of Pulmonary/Critical Care, Brooklyn VA Medical Center, State University of New York, Brooklyn

Michael S. Niederman, MD, FCCP

Winthrop University Hospital and State University of New York at Stony Brook. mniederman{at}winthrop.org

Nosocomial pneumonia (NP), and its most serious form, ventilator-associated pneumonia (VAP), is a major cause of morbidity and mortality in the ICU. Numerous controversies exist, from diagnostic criteria to prevention and treatment, including the issues of attributable mortality of VAP, differences in the approach to early and late VAP, and the best diagnostic methods. Initial, accurate therapy is one of the most important factors determining outcome in VAP. Antibiotic monotherapy versus combination therapy is not clearly defined, as clinicians struggle with the dual risk of inadequate therapy negatively affecting outcome and overtreatment promoting antibiotic resistance. The role of airway and gastrointestinal colonization and innovative preventive strategies such as noninvasive ventilation, antibiotic rotation, and aerosolized antibiotics are discussed. No uniform standards exist for the approach to VAP. The authors highlight the major controversies and dilemmas in the clinical approach to VAP, with recommendations for the bedside management of these patients.

Key Words: nosocomial pneumonia • prevention of pneumonia • antibiotic therapy • antibiotic resistance • pneumonia pathogenesis


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